Change Management in Action
Planning and implementing change in healthcare:
a practical guide for managers and clinicians
Nadia Gittins and Simon Standish
HLSP Institute
September 2010
Why
What
If
t
a
h
W
Who
How
About this booklet
contents
This booklet is aimed at senior clinicians and healthcare managers who would like help in thinking
through, planning and then implementing changes to their healthcare services locally. It provides
practical assistance in a way that assumes no prior theoretical background to what is often called
‘change management’.
Introduction
3
The Why of change
5
The What of change
8
The Who of change
10
The How of change
14
The What If of change
16
Case studies
17
The booklet is based on HLSP’s experience in
supporting individuals and organisations in
several countries including Nigeria and Russia.
Most recently, HLSP designed a successful
change management programme conducted
for over 400 Iraqi clinicians, administrators and
policy makers during 2007-2009. The aim of this
programme was to assist participants to become
Agents of Change in re-establishing their
healthcare system1.
There is a wealth of tools and techniques to help
with planning and achieving change. Based
on HLSP’s experience, the team refined the
approach and focused on the tools that really
help clinicians to formulate, sell and negotiate
their vision of change, and then to plan for
successful implementation. The tools presented
in this booklet are the ones that clinicians and
managers participating in change management
programmes considered most helpful.
We recommend that you read the Introduction
since this summarises the key issues and
approach taken. Thereafter you have a choice.
Either follow the booklet from beginning to end,
or go to the sections where you feel you will get
the most benefit.
1 For more information watch the film Agents of change: rebuilding Iraq’s medical system on
http://www.youtube.com/watch?v=_LHeLEvWdEo
2 | HLSP Institute
introduction
Why Change
Management Matters
Planning for
change
Changes to services and organisations can
often be difficult. Top down change can feel
threatening and destabilising. Many colleagues
find it difficult to see the potential benefits.
The changes may impact on the role, position
and the status of individuals and therefore may
test levels of self-confidence and confidence in
others.
The work of Organisational Development
practitioners has helped with ways of thinking
about the process of change, and the complex
reactions to it, at individual, organisational and
system level.
Change may require new clinical responsibilities,
time for training and development, and an
openness to new ways of doing things. It also
requires letting go of previous practice.
Change may require significant investment in
people, systems, equipment and facilities, and is
therefore likely to require financial backing.
These challenges make the planning of the
change process a prerequisite for success.
Well known models of change often assume a
linear progression from one state to another
(fig.1).
Fig.1 Beckhard and Harris’ model of change
Desired
future
state
Transition
state
Current
state
Getting from current to
desired state
This is a useful starting point but its simplicity
masks a number of more intricate and subtle
aspects associated with different phases of
change. These aspects require clear thinking,
communication and agreement on the reasons
for change and the longer term vision. A clear
assessment is required of who needs to be
involved in planning and implementing change
to make it successful.
Finally there needs to be a clear plan for change,
which also anticipates the potential pitfalls and
problems.
We brought these considerations together in an
effective framework which we called the ‘Five
Wonders of Change’ (fig.2, overleaf ).
This simple framework enabled clinicians to
study change made by other organisations, as
well as to prepare their own proposals and plans.
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The five Wonders of Change
Fig.2 The Five Wonders of Change
The Why of change –
this means assessing carefully the problems inherent within the
current set of services and organisation and why resolving these
problems is so important and urgent.
The What if of change –
this means giving attention to
potential problems early in the
planning process to minimise
the risk of late delivery and to
prevent failure.
Why
What if
The How of change –
this means knowing what action
is required in the short and
medium term to achieve the
desired set of changes.
How
What
Who
The What of change – this means
having a clear and compelling vision
of services and organisation with the
benefits that will be realised.
The Who of change –
this means knowing who may be key to championing
and promoting change as well as understanding who
might oppose or block it. Part of the thinking is on how
best to involve and work with these key individuals.
The next five sections set out each of the ‘Wonders of Change’ in more detail. The booklet ends with two case studies illustrating how the approach was used
by participants during the programme for Iraqi health professionals.
4 | HLSP Institute
The Why of Change
This is the first step on the road to change. If you and your colleagues are clear on
the reasons why change is needed and you are convinced of the urgency, then
the foundations are laid. If you are not clear, or the reasons are not shared by
those who matter, then change may fail to take off or will stall and fall away.
Most often change is driven by necessity or
in response to problems; there is something
wrong with the service or organisation that
requires fixing. The need for this can be seen in
performance data for health outcomes (mortality
or continuing morbidity), or in service efficiency
(waiting times or costs per unit). Performance
may have declined or just not be good enough
in comparison with other similar units.
The need for change may be made more
urgent because of changes occurring outside
the organisation. For example there may
be increased competition from other units,
regulators may move to close unsafe services,
healthcare purchasers may be looking for more
effective or less expensive alternatives or it may
be that there is a pressing shortage of skilled
labour which will undermine services.
By contrast, progressive external developments
can provide encouragement for change
internally. One example is the emergence of new
technologies offering benefits of better, safer
and less expensive healthcare. Other examples
include the availability of new funds and grants
to support change.
Whether the trigger is positive or negative,
there needs to be an internal desire for change
with a sense of urgency. The leader of a change
initiative can use the evidence gathered
during the why of change process to build this
collective desire.
A number of analytical tools and techniques can
assist with gathering data and building a rational
case for change.
ZUsing comparisons over time or with other
units on significant outcomes and measures
of performance (known as benchmarking)
ZSurveying users and healthcare purchasers
on the experience of service
ZThe systematic appraisal of the environment
using for example the PESTELI model (fig.3)
to understand the key trends in the factors
influencing change
ZThe systematic appraisal of the organisation
using for example McKinsey's 7-S (fig.4)
to understand how the various elements
relate and function together within the
organisation's internal culture
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The Why of Change cont.
Fig.3 PESTELI model for assessment of external
environment
Fig.5 The SWOT analysis
Fig.4 McKinsey's 7-S model
External Environment
Strengths
Weaknesses
Opportunities
Threats
Structure
Political factors
National government policies, local
policies, small ‘P’ politics
Economic factors
Availability of funding, nature of
competition
Sociological trends
Demographic trends (lifestyle, health
issues, behaviour)
Technological inNovations
Medical technology, information
Ecological factors
Environment, public health and systems
developments
Legislative requirements
Health, safety, employment
Industry analysis
Demand and supply issues
Strategy
Systems
shared
values
skills
style
staff
Z The integration of data and information
on the external and internal environment
(opportunities and threats) with conclusions
on the fitness or otherwise of the
organisation (strengths and weaknesses or
limitations), known as the SWOT analysis.
These tools and techniques will assist in
developing a rational presentation of the case
for change, focusing on a clear account of why
the current situation can not continue and what
would happen if no change was made.
Rational analysis will not in itself compel others
to consider change. For this to happen we
need to make connections with the underlying
motivations and drives of those who are most
affected. The case must have resonance with
human nature and the desire to generate
greater levels of certainty for the future and offer
satisfaction.
We will come back to the issue of motivation later
when we look at stakeholder engagement.
6 | HLSP Institute
Key points
Ownership of problems comes before ownership of solutions. The acceptance of the need for change
will be assisted by good rational analysis based on data with external validation. But the rational case
must also fit with the drives and preoccupations of key colleagues.
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The What of Change
Developing a vision of change is vital in clarifying the end result and in defining
success. It is also critical for inspiring others, building confidence and winning
support for the future.
But describing the vision can be difficult.
Ask yourself the question “if I came back in 12
months or two years what do I hope to see in
place and being achieved?” This will be your
vision.
Visions can be described in terms of outcomes
and benefits, services and organisational
features.
For outcomes, the vision may be described
in terms of the reduction of mortality and
morbidity, of infection rates, of lengths of stay
or increases in patient satisfaction. These are the
mirror image of the problems set out in the 'why
change' section but are set out now in positive
'benefit' terms.
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Some of these outcomes may take a long time
to achieve but they are the key drivers for your
change initiative and will form the basis of an
evaluation of success.
A vision focused on services and organisation
helps to present the desired changes with a
shorter term perspective before the benefits and
final outcomes are achieved.
For services the vision may set out a completely
different approach to serving patients. For
example the application of non-invasive surgery
offers new day case care without the need of inpatient services.
The provision of diagnostics in the community
offers a new locally accessible service close to
home. Integrating HIV services into mother and
child health care, or tailoring services to meet
the needs of young people, will affect both users
and providers in many ways.
In organisational terms, changes in staffing,
buildings and equipment are key enablers for
service delivery and for the achievement of
outcomes. Organisation changes will need to be
in place well in advance of the desired outcomes.
A vision of service and organisation will help
funders understand both the benefits being
sought (the outcomes) and the required
investments.
The vision for service is most important for
those who pay for healthcare and those who
use it. They will want to understand how service
changes might affect them.
Staff in an organisation will want to understand
their future role and contribution and how
change might affect their working and personal
lives. The vision of change in organisational
terms is most significant for this group.
Sometimes the vision of change is unclear. You
know about all the problems but the solutions
have yet to be identified and appraised.
In this situation the vision of change will have
to be described in terms of the journey and
first steps to make the vision clear. This is hard
for colleagues as anxiety is raised during the
discussion on the need for change, and remains
high given that no obvious solution exists or has
not yet been considered in detail.
Key points
A clear vision provides a positive view of the
future to counter the anxiety raised by the
acknowledgement of current problems and
issues. It will address desired outcomes and
describe both service and organisational
features. These aspects are vital to address the
different interests of key stakeholders. In the
early stages the vision of change may be clearer
about the desired outcomes than about the
specific solutions in service and organisational
terms. In this case the vision will need to include
something on the first steps of change.
HLSP Institute | 9
The Who of Change
Success in making difficult changes often depends on effective involvement of
key individuals or groups. But there are important judgements to be made on who
needs to be involved and how.
It is easy to generate lengthy lists of individuals
and organisations potentially affected by the
change. This exercise can rapidly become
unmanageable. So there is a need to focus effort
and energy on those who really can make or
break the change effort.
Fig.6 Stakeholder map
Fig.7 Assessing stakeholders' power and
interest
Stakeholder Key
(individual or interests
group)
and issues
Competitors
Shareholders
Media
Unions
The
organisation
Employees
Political
Customers
Public
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The next step is to plan how to manage the key
stakeholder groups to optimise levels of active
support and to minimise resistance (fig.8).
Power
(ability to influence or determine outcomes)
Suppliers
Financial
institutions
This is where we use assessments of power and
influence and make judgements about whether
individuals and organisations are likely to
advocate and champion change, or block it (fig.6
and 7).
High
Low
High
Low
Interest
(degree to which change might be of significance)
Fig.8 Planning stakeholder management
Desired
support or
project role
Actions and
communications
In order to make an accurate assessment it is
important to understand what motivates the
key stakeholders as well as considering their
personalities, temperaments, and their needs.
This will help you to take a view on:
Z How they might initially regard the change
(positive and negative);
Z What might provide some motivation to back
the proposals or how proposals might need
to change;
Z What role they may wish to play;
Z How they might be involved.
Fig.9 Motivation theories
Herzberg
Maslow
McClelland
Achievement
Work itself
Responsibility
Advancement and growth
Self-actualisation
Need for achievement
Esteem needs
Need for power
Belongingness
Need for affiliation
Recognition
Supervision and
relationships
Safety needs
Physiological needs
Job security
Pay and working conditions
There are many theories that can be employed
for an initial appraisal (fig.9 and 10)2.
Needs based theories of motivation can assist
in understanding the fears of loss that some
may associate with change, or what might be
potentially attractive.
2 For more information see Moorhead & Griffin, 1995.
HLSP Institute | 11
Fig.10 Application of the Myers-Briggs Type Indicator (MBTI)
Extraversion (E)
Introversion (I)
Sensing (S)
Intuition (N)
Decision
making
Thinking (T)
Feeling (F)
Preference for deciding according to
general truths, logic and objectivity
Preference for deciding according to
person-centred values and harmony
External
world
Judging (J)
Perceiving (P)
Energy
Information
gathering
Prefers to draw energy from the outside
world of people, activities and things
Preference for taking in information
through the senses, and focusing on the
here and now
Preference for closure, and a planned and
organised life
Theories of personality can assist in understanding
how best to communicate and work with
individuals. Some people will work best with data
and detail, others may be better at concepts and
ideas. Some will be more comfortable in large
groups, while others will need the opportunity for
individual reflection and small groups.
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Prefers to draw energy from the internal
world of ideas, emotions and impressions
Preference for taking in information
through insight, and noticing possibilities
Preference for spontaneity,
open-endedness and flexibility
Above all we need to recognise the various phases
of psychological change that organisations and
individuals might experience, in order to ensure
that the right level of communication and support
is offered at the right time.
For organisations or groups there may be
discernable and distinct phases of change;
moving from early steps to prepare the ground
to providing a platform for the next phases of
movement and then consolidation.
Both individuals and organisations experience the
turbulence of transitions from old to new. On a
personal basis the feeling of loss may come before
the exhilaration of gain. This is shown in the
Change Curve (fig.11).
Level of motivation and self-esteem
Fig.11 The Change Curve
Holding position
Key points
Contentious and difficult change requires sensitivity to
those affected. Change management begins to resemble a
political campaign starting with calculations about who is
affected and who needs to be involved, and then moving
to a plan of engagement working at the rational and
emotional levels.
Integration
Anger
Reflection
Impact
Bargaining
New practices
Depression
Acknowledgment
Time
HLSP Institute | 13
The HOW of Change
Being clear about the journey is important not only to reach the destination but
also to provide reassurance to those who are making the trip.
As mentioned in the previous section, significant
change programmes have a predictable set
of phases, requiring planning at both the
conceptual and more detailed level. This can
help to design the change process as a project,
with specific objectives and activities.
Fig.12 The big steps
Context
Long term
outcomes
Project objectives
Success criteria
Big steps
Approach
The big steps provide an overview of a change
programme which might last for weeks, months
or years.
14 | HLSP Institute
The first phase in the change process is often
the building of the case for change and the
development of clearer visions for services and
organisation.
The second phase ushers in a set of investments
around people, systems, processes and capital
assets, sometimes moving through intricate
pilots before permanent solutions are put in
place.
The third phase may be the commissioning of
new services, with evaluation and consolidation
occurring in the final stages.
Within the phases, we need much more detailed
plans toContext
address what needs to be done daily or
weekly.
Fig.13 The detailed plan
Big steps
Approach
Timescales
Key
milestones
Detailed
activities
Risks
Resources
Journey planning requires good process
thinking. By process we include all the rational
steps in moving from A to B as well as the steps
required to address the psychology of change.
If the process is effective, you will end up with
solutions that are grounded in reality and
command the support of key stakeholders.
Timescales
Key
milestones
Detailed
activities
Risks
Resources
Successful group work will require some more
process planning in terms of the tools and
techniques to be used in sessions to make
progress from problems to solutions. A wide
range of tools and techniques can be deployed.
Some of them support creative and divergent
thinking (brainstorming, and a range of
lateral thinking techniques), others facilitate
convergent thinking to explore in depth and
specific aspects of a task or problem in hand
(Fishbone analysis, problem analysis, decision
analysis)3.
Fig.14 The Fishbone
Major illnesses
Motivation and
morale
Levels of fitness
Levels
of employee
absence
Pay
Stress and work
Job satisfaction
All these elements will come together in the
form of a consolidated plan making clear the
mid-points of success as well as the actions and
the relationship between the actions.
The first steps are critical and many of these
may be focused on getting the key stakeholders
together to work on the case for change and the
vision (fig.15).
Fig.15 The consolidated plan
Stakeholder engagement
Total elapsed time for stakeholder engagement
Design survey
Test
Brief
Run survey
Gather results
Design workshop
Set up workshop
Run workshop
Write up results
Key points
The successful delivery of change needs to be
planned for each phase. Good process thinking
will move from big to small steps integrating
action to make progress on the task, as well as
influencing individual and group psychology.
You need to have a clear methodology with a
good choice of analytical tools and techniques.
But this needs to be combined with the most
effective processes of engagement of key
stakeholders to ensure acceptance, support and
commitment to solutions.
- Durations and dependencies
- Sequential and parallel tasks
- Critical path
Working
environment
3 For more information on these techniques see the references on page 25 on ‘Process thinking skills’.
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The WHAT IF of Change
The path of service and organisation change can be beset with problems and
pitfalls. Some will be political, others will be technical.
Many of the problems can be anticipated:
equipment and systems that don’t work or are
delivered late; poorly trained staff who find it
difficult to function in the new environment;
time and cost overruns due to late procurement;
rejections of proposals by key stakeholders.
Anticipating problems and analysing likely
causes is an essential part of managing risk
during change. The thinking around risk requires
challenging the original plan with a critical
eye. This is intended to test the robustness of
thinking.
16 | HLSP Institute
So we ask the question "What can go wrong?"
and we give priority to problems that are more
likely to occur and to those that have the most
significant impact on our change plan.
Risks can be avoided or minimised by preventing
problems occurring in the first place, or by
establishing contingency plans to deal with
them when they do arise.
Fig.16
The risk assessment and plan
Potential
problem
Consequences
Possible
causes
Preventive
actions
Contingency
plan
KEY POINTS
The ‘What If’ of change is deliberate 'negative
thinking' about what might go wrong. This
is essential to develop a sound approach to
change which takes potential risks into account.
A collective assessment of problems and their
causes can open up positive thinking to prevent
or minimise the risks.
Case Studies
Two case studies illustrate the application of the Five Wonders of Change. Case Study 1 is based on a change process developed by a group of participants in
the programme for Iraqi health professionals and then implemented on their return to Iraq. Case Study 2 is drawn from a review of UK-based change processes
conducted by Iraqi doctors.
1. The introduction of training programmes for improved
self-management by diabetes patients
The Why of Change
Box 1 - Why change is needed on diabetes care in Iraq
Participants began their assessment of the
current situation with an analysis of the
incidence of diabetes within the general
population in Iraq, and the consequences
of poor management of the condition for
individuals and their families (Box 1).
Public health issues
Z Increasing prevalence of Diabetes Mellitus
(DM)
ZUnderstanding the disease, its treatment
and complications is highly important for
patients to live normally
Z Poor disease management leads to
complications, resulting in increased
vascular disease and the associated risks of
limb amputation and blindness
Z Poor control and complications of type 1 DM
are due to poor educational standards
The groups then used a strengths and
weaknesses (SWOT) analysis to comment on
the current approach to education for patients
on improved self-management.
Assessment of current approach
Z Diabetes management including education
is undertaken by doctors in outpatient clinic
time
Z Doctors have limited time; as a result
patients have limited understanding of the
disease and what they can do to self-manage
ZThere is no specific educational program for
health care centres and general hospitals
ZSome specialised diabetic centres provide
basic education programmes, but do not
follow modern evidence based approaches
HLSP Institute | 17
The What of Change
Box 2 - The vision of change
The project made clear the desired health
and quality of life benefits for individuals and
communities, as well as the desired economic
impact, as costs of hospital care are reduced.
The vision of outcomes and benefits
Z Preventing disease complications
Z Reduction of the economic burden on
the patient, health care facilities and
community
Z Reduction in hospitalisation rates
ZEasing the burden on doctors
Z Giving patients the choice to eat a
normal diet
Then participants went on to set out their
vision of the training programme and the
team that would be required to support
patients and their families (Box 2).
At this stage it is a broad vision, with much of
the detail to be worked out in the early phase
of the project (for example how many trainers
there should be and where the training
should take place).
The vision of service
ZTranslation and accommodation of
international DAFNE4 approach in Iraq
ZEstablishing effective education and
training programme at the level of
primary health care centres, and in
more advanced health care facilities
(e.g. general hospitals)
The vision of organisation
Z Improve the educational standards of
medical staff and patients
Z Initiation of a team capable of handling
all aspects – helping patients in Primary
Health Centres (PHCs) and assisting in
the establishment of similar programmes
in other PHCs and other major general
hospitals
Z Making the treatment of this disease a
team effort, rather than just a doctorpatient effort
4 Dose Adjustment For Normal Eating (DAFNE) is a way of managing Type 1 diabetes.
18 | HLSP Institute
The Who of Change
A long list of stakeholders had to be
considered to move forward the project.
These ranged from patients and their
families to healthcare professionals and
policy makers.
The assessment of power and interest
placed emphasis on the executive senior
manager of the hospital and senior doctors.
However it was clear from later analysis that
some of the less powerful but supportive
stakeholders could be enabled to have
more leverage on discussions. General
Practitioners (GPs) were seen as a key
group with influence, but little interest at
this stage. They then became the focus for
analysis, and specific actions were identified
to engage them.
Box 3 - Stakeholder analysis
High interest, high power
High interest, low power
1.
2.
3.
1.
2.
Ministry of Health
Senior doctors
Executive senior manager
3.
Patients
Some of the doctors (especially senior
doctors)
Junior health workers and some of the junior
doctors
High power, low interest
Low power, low interest
1.
2.
3.
4.
1.
Patients
2.
Health care workers
3.
Junior medical staff
Senior doctors
Senior administrative managers
Other health workers, senior managers
Non-governmental organisations
4.Nurses
How to gain the interest of GPs toward the project?
Z Meet groups of GPs
Z Inform them about the benefits of the project
Z Ask them for help and support
Z
Z
Z
Z
Involve them in the project
Give them opportunity for training
Listen to their feedback
Rewards (gifts, certification, financial support)
HLSP Institute | 19
The How of Change
Box 4 - The plan of change
The What if of Change
Participants identified the
key steps in moving forward
with the introduction of the
training programme. The
example (Box 4) shows that
there is a phased approach
to implementation, with a
trial programme in the first
phase prior to wider roll out.
1. Identification of the managing team
2. Development of curriculum
3. Attracting funds
4. Identification of executive teams
5. Choosing the training medical centre
6.Starting the trial programme
7. Follow up
8. Launching a wider programme
9. Monthly training courses for more than 20
paramedical staff
10. Periodical training courses for doctors in PHCs
and general hospitals
In reviewing the plan participants identified a number of
potential problems (Box 5). Poor trainee performance was
seen as particularly problematic. Incentives would need
to be put in place at the outset, and retraining offered as a
contingency in case of poor performance.
Key risk areas
Activity
Approval (1)
Logistics (1)
Conduction of
DAFNE (3)
Evaluation, feedback
and audit (3)
Adaption of DAFNE in PHC (6)
Feedback of DAFNE
in PHC (3)
Revalidation and
audit (3)
2
3
4
5
6
7
8
Time (Months)
20 | HLSP Institute
9
10
11
Likely causes
• Poor trainee
• Poor calibre
• Lack of
performance
motivation
• (high
probability,
• high
consequences)
Planning
(GANT Chart)
Communication
(1)
1
Box 5 - Risk assessment
12
Preventive
action
Contingent
action
• Rigorous
selection
• Work on
reward and
recognition
programme
• Re-training of
staff
2. The development of a new Urgent Care Centre within
community based Walk-in Centres
The Why of Change
Box 1 - Why change is needed in urgent care
Participants began their assessment of the
current state with an analysis of the current
local system for urgent unscheduled care.
They used a strengths and weaknesses
analysis to draw conclusions on the need for
change locally.
Current system
Z Local Accident and Emergency (A&E)
department within specialist teaching hospital
Z 2 local walk-in centres (1 located by A&E)
Z 50 local General Practices and Out of Hours
services
Z 35 pharmacies
ZSpecialist clinics for sexual and mental health
ZThe Ambulance services
ZNHS Direct
Strengths and weaknesses
ZExtensive range of options for local residents
and visitors
ZEase of transport links to the local hospital
Z Increased use of A&E leading to long waits and
higher costs per case
ZUp to 40% of A&E attendances for primary
care conditions
Z High numbers of discharge without follow up
Z Higher admission rate
Z Difficulties in gaining access to GPs during
hours for urgent consultations
Z Confusion by members of the public on which
service to use when
Z Cost burden of unnecessary hospital care
ZUnaffordability of system given population
growth
HLSP Institute | 21
1
2
3
4
5
6
7
8
9
1
10
0
11
12
TTime
ime
e ((Months)
Mo
M
on
ntth
hsss)
The What of Change
Box 2 - The vision of change
The vision for service covered outcomes and
desired benefits for the community in terms of
access to the service as well as value for money
for taxpayers (Box 2). The vision for service was a
new model showing support for urgent and non
life threatening conditions from enhanced local
primary care networks and four local urgent care
services. Access would be assisted by one call
centre. Emergency and trauma services would
continue to be provided by the local hospital.
The vision of outcomes and benefits
ZEasily accessible and understandable system for local people
Z Improved locally accessible services
Z Reduced waiting times
Z Better use of hospital system and improved value for money
ZEnhanced information and service for self-management
The vision of service
The services
The points of access
and enablers
1 Major Trauma Care
A&E
TH population
230,000 (2007)
270,000 (2016)
Borough based
or larger
Locality based services
or across localities
Local networks (within
walking/easy travel)
4 Urgent Care
Centres
10-15 Local networks
of GPs, pharmacists.
Drawn from: Tower Hamlets Urgent Care Strategy, 2008-2014
22 | HLSP Institute
Urgent Care
Assessment Team
(walk-in/telephone)
London Ambulance
Service
NHS Direct
Public information
The Who of Change
Box 3 - Stakeholder analysis
The How of Change
A long list of stakeholders had
to be considered to move the
project forward. These ranged
from patients and their families
to community and hospital
based healthcare professionals,
the Ambulance service and
NHS Direct. Analysis of current
service use showed that
considering the particular
needs of different local groups
was key to understanding
current preferences and
designing the new local
centres.
Key stakeholders
Z Local communities and user
representatives
Z GPs
Z Hospital based A&E consultants
and senior nurses
Z Primary Care purchaser
Z Key clinical representative groups
Z Local Authority
The change programme was built around a number of
developmental phases. In this way investment in people, systems
and facilities could be carefully planned and then implemented
to ensure smooth assimilation of new services with re-shaping of
existing services.
Box 4 - Plan of change
•
Segmentation of community groups
Z By locality
Z By age group
Z By ethnicity
•
•
Phase 1 Formal establishment of new processes at the
front end of the A&E department with incorporation of an
assessment team. Start up of first set of new community
facilities. Establishment of new telephone service and
enhanced access to local GP services.
Phase 2 Opening new purpose built emergency and trauma
services at the new hospital. New clinical assessment and
management pathways in place and utilised in the Urgent
Care Centre based at the front end of A&E.
Phase 3 Opening of three other new Urgent Care Centres
in the localities. Roll out of clinical guidelines and pathways
developed for the hospital based Urgent Care Centre.
HLSP Institute | 23
The What if of Change
Table 2 Risk assessment for urgent care development
This was an extensive five-year change
programme and given the length and
complexity of the programme, there
were a number of risks to be assessed.
These included macro risks arising from
the general economic climate to more
localised risks involving continued
reliance on the hospital despite the
investment in new facilities.
Key risk areas
1. Less money available
for investments in
local system
Likely causes
• General economic
situation
2. Local people continue •
to look to hospital for
care
•
•
3. Workforce shortages
undermine new
services in the
community
24 | HLSP Institute
•
•
Preventive action
• Development of
more flexible plans
within each of the
phases based on two
financial scenarios
Lack of awareness of
• Planned local
alternatives and ease
marketing campaigns
of access
using local media
Continuing difficulties
and key information
in accessing local GP
points
Continued belief that • Clear focus on
best care is to be
improving access to
found in the hospital
GP services
Insufficient numbers
• Urgent attention
in training for new
given to workforce
nursing positions
plan
Inability to recruit
• Work with local
locally
partners to promote
opportunities for
local people
Contingent action
• Revision of phases
of change at the
end of phase one
•
Revision of
incentives to
ensure that local
commissioners
take prompt
action to influence
local behaviour
•
Plans for redeployment of
nursing skills
to cover critical
shortages
Further reading
Process thinking skills
De Bono, Edward (1970). Lateral Thinking: A Textbook of Creativity. London: Wardlock Educational Ltd.
De Bono, Edward (1971). Lateral Thinking for Management. London: McGraw Hill.
De Bono, Edward (2000). Six Thinking Hats. London: Penguin Books.
Kepner, Charles H and Tregoe, Benjamin B (1965). The Rational Manager. Kepner Tregoe.
Kepner, Charles H and Tregoe, Benjamin B (1997). The New Rational Manager. Kepner Tregoe.
Knight, S (1998). NLP at Work: The Difference That Makes the Difference in Business. London: Nicholas Brealey.
Longman, Andrew and Mullins, Jim (2005). The Rational Project Manager. Hoboken, NJ: John Wiley and Sons Inc.
Moorhead G, Griffin RW (1995) Organisational Behaviour: Managing People and Organisations. 4th ed. Boston: Houghton Mifflin.
Pande, Peter S, Neuman, Robert P and Cavanagh, Roland R (2002). The Six Sigma Way. London: McGraw-Hill.
Rasiel, Ethan M (1999). The McKinsey Way. London: McGraw-Hill.
Schein, Edgar H (1969). Process Consultation: Its Role in Organization Development. London: Addison–Wesley Publishing Company.
Senge, Peter et. al. (1995). The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. London: Nicholas Brealey Publishing.
HLSP Institute | 25
Further reading cont...
Change management
Axelrod, Richard H (2000). Terms of Engagement: Changing the Way We Change Organizations. San Francisco: Brett-Koehler Publishers, Inc.
Bargar, NJ and Kirby, LK (1995). The Challenge of Change in Organizations: Helping Employees Thrive in the New Frontier. Palo Alto: Davies-Black.
Beckhard, Richard and Harris, Reuben (1987). Organizational Transitions. Managing Complex Change 2nd Edition. Reading, MA : Addison-Wesley Publishing Co
(Addison Wesley Organizational Development series).
Beer, M and Nohria, N (2000). “Cracking the Code of Change”. Boston: Harvard Business Review, May – June: Product No. R00301.
Bridges, W (2002). Managing Transitions: Making the Most of Change. London: Nicholas Brealey.
Bridges, W (1996). Transitions: Making Sense of Life’s Changes. London: Nicholas Brealey.
Briggs Myers, I and Myers, PB (1995). Gifts Differing: Understanding Personality Type. Palo Alto: Davies-Black.
Conner, Daryl R (1998) Managing at the Speed of Change: How Resilient Managers Succeed and Prosper Where Others Fail. NY: John Wiley & Sons.
Covey, SR (1999). The 7 Habits of Highly Effective People. New York: Simon & Schuster.
Downey, M (2001). Effective Coaching. London: Texere.
Fritz, R (1999). The Path of Least Resistance for Managers. San Francisco: Berrett-Koehler.
Janov, Jill (1994). The Inventive Organization: Hope & Daring at Work. San Francisco: Jossey Bass Publishers.
Kotter, John P (1990). A Force for Change: How Leadership Differs from Management. London: Collier Macmillan Publishers.
Kotter, JP (1996). Leading Change. Boston: Harvard Business School Press.
Loup, Roland (1993). “A Model that Describes Conditions Necessary for Change” Ann Arbor, MI: Dannemiller Tyson Associates, Inc.
Pegg-Jones P, Standish S (2006) People Projects and Change, Premium Publishing, London
Quirke, B (2000). Making the Connections: Using Internal Communication to Turn Strategy Into Action. Aldershot, Hampshire: Gower.
Sirkin, Harold L, Keenan, Perry and A Jackson (2005). “The Hard Side of Change Management”. Boston, Harvard business Review, October: Product No 1916.
26 | HLSP Institute
“
My whole way of
thinking changed, and
this has helped me with
the various projects that
I have been carrying out
in my hospital.
An Iraqi programme participant
”
HLSP Institute | 27
Change management has found recognition as a
discipline mainly across the private and public sectors
of developed countries, but has been used less
frequently in the context of developing and middle
income countries.
At HLSP we have applied change management tools
and techniques within projects in those countries.
We have drawn from our experience to produce this
practical, jargon-free guide to change management.
The booklet sets out the five key steps for the
successful planning and implementation of change.
The approach is illustrated with project examples
from HLSP’s recent programme supporting doctors
from Iraq to bring change to their healthcare services.
HLSP Institute
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The Institute is HLSP’s knowledge centre. Through its publications and learning products, the HLSP Institute contributes to debate and policy on global health issues.